DR Ayesha Presentation

CASE SCENARIO
A 60 year old man presents to surgical ER with complaint of colicky

abdominal pain, distension, vomiting and absolute constipation.
Patient is vitally stable. On examination, there is a midline
laparotomy scar as he underwent surgery for typhoid enteritis.
Abdomen is protuberant with exaggerated bowel sounds.
What will be your provisional diagnosis? underlying cause?

INTESTINAL OBSTRUCTION
Dr. Ayesha Shaukat

House Surgeon
Surgical Unit-I
DIFFERENTIAL DIAGNOSIS
Ascites History of jaundice or pain in RHC, other
signs of liver disease
Medications Antidepressants, narcotics
Mesenteric ischemia History of PVD, hypercoagulable state,
post-prandial abdominal pain,
vasopressor use
Perforated viscus/ intra-abdominal sepsis Fever, leukocytosis, acute abdomen, free
air under diaphragm on X-ray
Post-operative paralytic ileus Recent abdominal surgery with no post-

op or flatus bowel movement
Ogilivie syndrome/ acute colonic pseudo- History of intestinal dysmotility, diabetes
obstruction mellitus, scleroderma
BACKGROUND
Intestinal obstruction is defined as partial or complete Arrest / blockage of
onward propulsion of intestinal contents
Classification
Simple
1. Pathological
Strangulated
Small intestine
2. Level of obstruction
Large intestine
Acute
3. Onset and course Subacute
Chronic
4. Dynamic vs adynamic
5. Complete vs incomplete
Dynamic vs Adynamic Obstruction
Dynamic Obstruction Adynamic Obstruction
Peristalsis is working against a No mechanical obstruction

mechanical obstruction.
Peristalsis is “absent” or
“inadequate”
INCIDENCE
• Small Intestine - 85% Large Intestine - 15%
• Adhesions - 60% • CA colon - 65%

• Hernias - 15% • Diverticulitis - 20%
• Tumors - 15% • Volvulus - 5%
• Miscellaneous - 10% • Miscellaneous - 10%
PATHOPHYSIOLOGY
HISTORY
EXAMINATION
• INSPECTION - To find evidence of any:
• Surgical scars
• Hernias
• Distension
• Visible Peristalsis
EXAMINATION
• PALPATION – Palpate for:
• Tenderness/Rigidity
• Masses
• Hernias
Perform digital rectal examination. Findings you would expect?

EXAMINATION
• PERCUSSION -
To hear any dullness or resonance related to site of obstruction.
• AUSCULTATION -
Bowel sounds are initially loud and frequent – then as bowel distends they
become hyper resonant and high pitched, eventually becoming amphoric.
SIGNS OF STRANGULATION
Constant, severe pain
Fever (>100⁰F)
Tachycardia (>100 beats/min)
Peritoneal signs- generalized rigidity, rebound tenderness
Percussion tenderness
Absent bowel sounds
INVESTIGATIONS
Hematological findings include:
• Leukocytosis- infection/ strangulation

• Serum electrolytes - vomiting and diarrhea
• Serum urea and creatinine – dehydration
• Metabolic acidosis – in distal obstruction due to combined
effects fo dehydration ketosis and loss of alkaline secretions
RADIOLOGICAL
• X-ray Abdomen (erect and supine films)

• Ultrasound
• Contrast studies
• Enteroclysis
• CT scan
6c
3 cm m
Small bowel obstruction

Large bowel Obstruction
RADIOLOGICAL FEATURES
Small Bowel Large Bowel
 Dilated bowel loops lie central  Peripherally dilated bowel

and transversely. loops
 Jejunum is characterized by its  Haustral folds in the colon, are

valvulae conniventes, which spaced irregularly, do not cross
completely pass across the the whole diameter of the
width of the bowel and are bowel and do not have
regularly spaced, giving a indentations placed opposite
‘concertina’ or ladder effect. one another.
 Ileum – featureless  Distended caecum is shown by

 No/ minimal gas is seen in the a rounded gas shadow in the
colon right iliac fossa
ULTRASOUND – SMALL BOWEL OBSTRUCTION
Typical Ileocecal Obstruction- Stepladder pattern
DOUBLE BUBBLE SIGN
VOLVULUS
A twist / rotation of segment of bowel upon its mesentery
INTUSSUSCEPTION
Telescoping of one hollow structure into its distal hollow structure

CLOSED LOOP OBSTRUCTION
• Afferent and efferent limbs both are
obstructed and distension is principally
confined to the closed loop.
• e.g. in case of malignant stricture of the

colon with a competent ileocaecal valve.
CONTRAST STUDIES
ENTEROCLYSIS
CT Scan - To find evidence of any:
• Abcess
• Tumor
• Hernia
• Bolus
MANAGEMENT
“The sun should not both rise and set on a complete intestinal
obstruction.”
CONSERVATIVE- Three main measures:

GI Drainage
Fluid and electrolyte replacement
Relief of obstruction, usually surgical
MANAGEMENT
• Two wide bore IV lines

• Foley Catheterization and nasogastric decompression
• Resuscitation
- Start Ringer Lactate
- Add KCl to fluid
• Analgesia
• Broad spectrum antibiotics - for gram-negatives and anerobes
• Vital and input output monitoring

• Abdominal girth
• Follow labs for TLC, serum electrolytes, hematocrit
SURGICAL MANAGEMENT
Principles of surgical intervention include management of:

• The segment at the site of obstruction
• The distended proximal bowel
• The underlying cause of obstruction
Indications for early surgical intervention

• Obstructed external hernia
• Clinical features suspicious of intestinal strangulation
• Obstruction in a ‘virgin’ abdomen
Thank you!
Any Questions?

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CASE SCENARIO

A 60 year old man presents to surgical ER with complaint of colicky

What will be your provisional diagnosis? underlying cause?

Dr. Ayesha Shaukat

Post-operative paralytic ileus Recent abdominal surgery with no post-

Peristalsis is working against a No mechanical obstruction

• Adhesions - 60% • CA colon - 65%

Perform digital rectal examination. Findings you would expect?

Hematological findings include:

• Leukocytosis- infection/ strangulation

• X-ray Abdomen (erect and supine films)

Small bowel obstruction

 Dilated bowel loops lie central  Peripherally dilated bowel

 Jejunum is characterized by its  Haustral folds in the colon, are

 Ileum – featureless  Distended caecum is shown by

Telescoping of one hollow structure into its distal hollow structure

• e.g. in case of malignant stricture of the

CONSERVATIVE- Three main measures:

• Two wide bore IV lines

• Vital and input output monitoring

Principles of surgical intervention include management of:

Indications for early surgical intervention

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